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State ‘Accountable Care’ Activity Map

With the support of The Commonwealth Fund, NASHP is tracking state efforts to lead or participate in accountable care models that include Medicaid and Children’s Health Insurance Program populations. Accountable care models aim to address lack of care coordination and wide disparities in cost and quality of care in the U.S. health care system, perpetuated by the prevailing fee-for-service payment method, through shared incentives to manage utilization, improve quality, and curb cost growth.

Key Domains: State accountable care activity is characterized on this map along seven domains.

ACO Map

Click state for more information. At this time, we have no information on accountable care activity that meets the criteria.*

Project scope refers to a range of model design characteristics, including targeted providers, targeted beneficiary population, scope of services provided, and methodology for assigning beneficiaries to the model.

Eligible Patient Population: Alabama Medicaid plans to directly contract with regional care organizations (RCOs) for the majority of the Medicaid population (approximately 800,000 beneficiaries). The state would continue and/or expand the existing enhanced primary care case management program (the Patient Care Networks of Alabama program) while the RCOs are under development. Most Medicaid beneficiaries would be included while dual eligibles, those in long term care facilities or utilizing home and community-based waiver services, and the developmentally disabled would be excluded from the initiative.

Scope of services: Community-led RCOs would manage and coordinate care for the majority of the non-dually eligible Medicaid population. Through a capitated payment, RCOs would manage the full scope of Medicaid benefits, including physical, behavioral, pharmacy and long-term care services.

The state’s 1115 Waiver Concept Paper envisions building the RCOs over time, potentially by phasing them in as pilots across the state. Regions may first opt to develop a PCNA program to serve as the foundation for a future RCO. RCOs would initially manage and be at risk for primary, acute and post-acute care services. As they build capacity, they would be expected to integrate and fully manage behavioral health services for the population served. RCOs will be required to design care coordination programs to ensure these beneficiaries have access to adequate physical and behavioral health care in addition to connecting them with social services.

Provider Population A RCO may contract with any willing hospital, doctor or provider to provide services in a Medicaid region if the provider is willing to accept the payments and terms offered to comparable providers. Providers should meet licensing requirements set by law and have a Medicaid provider number. As stated in the initiative’s Planning Principles, any willing provider who chooses to apply does so not only within his or her region, but also across regional lines. Mental health and substance abuse providers currently certified by the Alabama Department of Mental Health (ADMH) and functioning as approved Medicaid providers are expected to be critical participants in RCO and PCNA networks.

Federally Qualified Health Centers (FQHCs) are also expected to play a role in the development of both the RCOs and PCNAs as critical primary care providers.

Attribution In June 2013, Alabama’s Medicaid agency divided the state into 5 RCO regions. All affected beneficiaries would be required to enroll in an RCO or PCNA based on geographic location. To the extent there is more than one RCO in a region, beneficiaries would retain the right to choose between RCOs; beneficiaries who do not choose will be auto-assigned. Beneficiaries will also retain their choice of medical provider and medical/health home within network.

ProviderPopulation: The Arkansas Health Care Payment Improvement Initiative includes all providers who provide care for Medicaid, Arkansas BlueCross BlueShield, and Arkansas QualChoice; participation is mandatory. Five episodes are initially included in this initiative; providers who do not provide these services or who have limited case-volume are also excluded.

Scope of Services: The initiative will begin with five episodes of care, though the initiative’s long-term goal for is to have episode-based payment for the majority of episode types within five years. The five initial episodes will be Attention Deficit Hyperactivity Disorder (ADHD), upper respiratory infections, congestive heart failure, hip and knee replacement, and perinatal care. A preparatory phase for these five episodes, which serves as a time for providers to adjust to the new system and for payers to begin collecting preliminary data, launched in July 2012; the performance period began in October 2012.

Attention Deficit Hyperactivity Disorder (ADHD): Defined as care over a twelve-month period, and includes all ADHD services and pharmacy costs.

Upper respiratory infections: Defined as the care delivered in the 21 days following initial consultation; includes colds, sore throats and sinusitis. Hospital stays and surgical procedures are excluded.

Congestive heart failure: Defined as care given from the time of hospital admission for heart failure to 30 days following discharge.

Hip and knee replacements: Defined as care delivered from 30 days prior to 90 days after surgery.

Attribution: Payers use claims data to designate a principal accountable provider (PAP) (a “care quarterback”) for each episode based criteria for each episode type; the PAP can be a provider, a group of providers, or a practice or hospital. The PAP is identified differently for each episode type; for example, the PAP for a hip or knee replacement (see slide 10) is the orthopedic surgeon. PAPs are responsible for cost and quality of care throughout each care episode, including care provided by other members of the patient’s care team.

Scope of services: California Public Employees’ Retirement System (CalPERS) members participating in the accountable care organization (ACO) pilot are receiving a range of health services, which are divided into “cost categories” for the purpose of assigning risk to Blue Shield and the participating providers. The cost categories of financial risk that fell under the pilot’s target cost cap were: facility costs (partner hospital, out-of-area non-partner hospital, and other non-partner hospital), professional costs, mental health costs, pharmacy costs, and ancillary costs.

Provider population: The pilot extends only to select practices and hospitals: Hill Physicians in three counties and four Dignity Health hospitals.

Eligible patient population: Roughly 41,000 CalPERS members are participating in the ACO pilot, all via their enrollment in Blue Shield NetValue and Access+ HMO health plan in four counties. CalPERS offered a premium discount for selection of the plans participating in the ACO demonstration.

Provider Population: Rollout of the Accountable Care Collaborative (ACC) was phased (see slide 15 in link): in the initial phase, Regional Care Collaborative Organizations (RCCOs) chose communities in which to implement the pilot. During the expansion phase, which began in July 2012, implementation is statewide across the program’s seven regions. Each region has one RCCO. RCCOs are expected to work with patients’ Primary Care Medical Providers to coordinate care, ease care transitions between settings, and connect beneficiaries with specialist services as needed.

Patient Population: This program serves Medicaid fee-for-service and Primary Care Physicians Program (a Colorado Medicaid health plan) beneficiaries. Dual eligible and beneficiaries residing in an institutional setting are excluded from the program, as are clients enrolled in Medicaid managed care. The number of children enrolled in the program was initially limited to approximately one-third of the number of total enrollees; the Department plans to remove this limit in October 2012. In addition, beneficiaries are not enrolled if they have a regular provider who is not participating in the ACC program. Enrollment is voluntary and passive for most beneficiaries, though enrollment is mandatory for adult Medicaid beneficiaries without dependent children. In addition to Medicaid beneficiaries, patients with a history of seeing a provider who is participating in the federal Comprehensive Primary Care Initiative will also be enrolled in the ACC program beginning November 1, 2012.

As of June 2013, total program enrollment was 352,236, including 222,862 children. Overall, forty-seven percent of Medicaid beneficiaries in the state are enrolled in the program.

Eligible Patient Population: The three health centers that comprise the Accountable Healthcare Alliance of Rural Oahu (AHARO) serve a total of approximately 40,000 patients through over 200,000 clinical visits annually. Approximately 50% of these patients (20,000) are enrolled in the Hawaii QUEST (Medicaid) program.

QUEST members continuously enrolled in a participating health plan and assigned to a participating health center for at least 3 months are considered to be enrolled in AHARO for the purpose of defining financial performance metrics (see Appendix F).

Eligible Provider Population: AHARO is forming partnerships both with a vertical network of providers and with selected Medicaid managed care organizations. Providers are affiliated with the three participating health centers: Koolauloa Community Health and Wellness Center, Waimanalo Health Center, and Waianae Coast Comprehensive Health Center.

Enrollees in a CCE must also be enrolled in Illinois Health Connect, the state’s Medicaid primary care case management program. Medicaid beneficiaries who are enrolled in a managed care organization are not eligible to enroll in a CCE. Initially, the choice to enroll in a CCE or MCCH is voluntary.

Provider population: ACEs must include primary care, specialty care, hospitals, and behavioral health providers. CCEs are required, at a minimum, to include primary care providers, hospitals, mental health providers, and substance abuse providers. The matchmaking tool developed by the Illinois Department of Healthcare and Family Services allows community partners interested in forming a CCE to search for a range of potential partners, including general hospital, primary health clinic, public health, home health, hospice, medical equipment, social service/community-based, and dental partners.

Primary care physicians may be enrolled in more than one CCE or MCCN.

Attribution: Enrollees select an ACE, CCE or MCCN and are locked into their choice for 12 months; they may change CCEs or MCCNs during an annual open enrollment period.

Scope of Services: Entities applying to participate in the Care Coordination Innovations Project as an ACE, CCE or MCCN must be able to coordinate care across the spectrum of the health care system with a particular emphasis on managing transitions between levels of care and coordination between physical and mental health and substance abuse.

Under Public Act 096-1501, care coordination must include providing or arranging for a majority of care around the patient’s needs, including a medical home with a primary care provider, specialist services, diagnostic and treatment services, mental health and substance abuse services, inpatient and outpatient hospital services, and rehabilitation and long-term care services.

The initial solicitation for proposals specifies that MCCNs must, at a minimum, assume risk for services included in Service Package I of the state’s Integrated Care Program: all standard Medicaid medical services, such as physician and specialist care, emergency care, laboratory and X-rays, behavioral health, pharmacy, behavioral health and substance abuse services.

Scope of Services: The Iowa Wellness Plan members will receive a comprehensive, commercial-like benefit package based on the State Employee Plan benefits, which will ensure coverage for all of the essential health benefits as required by the Affordable Care Act. Iowa will supplement the State Employee Plan services with supplemental dental benefits, similar to those provided in the Medicaid State Plan. Mental health and substance use disorder and dental benefits will be provided on as carved out benefits on a contracted basis.

Eligible Provider Population: Iowa’s ACO strategy under its Iowa Wellness Plan is centered on Patient Managers, providers that signed both a Wellness Provider Agreement and a Medicaid Provider Agreement, are part of an ACO, and agree to accept the terms of the agreement with the ACO to serve as a primary care/patient-centered medical home for the member.

Eligible Patient Population: The Iowa Wellness Plan is targeted for individuals who are between ages 19 through 64 who do not have access to Medicare or other comprehensive Medicaid coverage, and who are not eligible for cost-effective employer-sponsored coverage. Individuals, who do not have access to cost-effective employer-sponsored coverage, with income up to and including 100 percent of the federal poverty level (FPL) based on the modified adjusted gross income methodology, are considered eligible, and individuals with income up to 133 percent of the FPL who are medically frail will be considered eligible.

Attribution: Medicaid beneficiaries enrolled in the Iowa Wellness Plan choose a primary care provider (known as a Patient Manager); the beneficiary is assigned to the ACO if the primary care provider is participating. If a beneficiary does not choose a provider, he is assigned to the provider with whom he had the highest number of unique visits (using evaluation and management codes in the most recent 12 months of claims history).

Patient population: Participation in coordinated care networks in Louisiana is mandatory for categorically needy children up to 19 years of age and their parents; pregnant women; aged, blind, and disabled adults; uninsured women under the age of 65 who have been identified as being in need of treatment for breast and/or cervical cancer; uninsured women eligible through the Louisiana Children’s Health Insurance Program Prenatal Option; and medically needy individuals and families.

Attribution: As part of the eligibility determination process, Medicaid and LaCHIP applicants shall receive information and assistance with making informed choices about the CCNs in their area of residence and the availability of choice counseling. These individuals will have the opportunity to talk with an enrollment broker who shall provide additional information to assist in choosing the appropriate CCN.

Each new recipient is given at least 30 calendar days from the postmark date of an enrollment form mailed by the enrollment broker to select a CCN and primary care provider (PCP). Recipients who fail to choose a CCN will be auto-assigned.

Eligible Patient Population: All MaineCare members who receive full MaineCare benefits, including Categorically Needy, Medically Needy, SSI-related Coverage Groups, Home and Community-Based Waiver and HIV Waiver members, and others are eligible for attribution to the Accountable Communities.

Provider Population: All willing and qualified providers will be eligible to participate in the Accountable Communities initiative. Accountable communities will not be limited by geographic area.

Attribution: The Department of Health and Human Services has proposed to align Accountable Communities’ member attribution methodology with that used in the Medicare Pioneer Accountable Care Organization program.

Based on historical claims analysis, members will be prospectively assigned to an Accountable Community associated with the primary care practice or specialist where they received a plurality of visits for primary care services (as defined by HCPC codes or revenue codes for Federally Qualified Health Centers). Members who moved or received more than 50 percent of their primary care services in a non-contiguous geographic region to the Accountable Community will be excluded after the performance year. Members not assigned through a primary care or specialty practice will be assigned to the Accountable Community associated with the hospital where the member receives the majority of their emergency department care. Member freedom of choice will not be restricted.

Scope of services A Request for Applications issued by the state in October 2013 lists the defined set of 26 core services that will be factored into the total cost of care calculation for Accountable Communities. These services include primary care case management, behavioral health, inpatient and outpatient services, pharmacy, hospice and home health. Additional optional services—including dental, children’s private non-medical institution, and long term care services—can be included in the Accountable Community’s total cost of care at the Accountable Community’s discretion.

Medically necessary services not internally available must be provided to patients outside the ACO. More detailed regulations on the scope of services offered by ACOs are forthcoming.

Eligible Provider Population: Provider organizations that meet the criteria for participation set in the statute (and supplemented by forthcoming regulations) may apply to become an ACO. The legislation specifies that provider organizations include any corporation, partnership, business trust, association or organized group of persons, that is in the business of health care delivery or management and represents one or more health care providers in contracting with insurers for the payments of heath care services. This includes physician organizations, physician-hospital organizations, independent practice associations, and other provider networks.

Eligible Patient Population: Participating patient populations are not addressed in the legislation.

Attribution: Attribution of patients to ACOs is not described in the legislation.

Eligible patient population: Most Medicaid enrollees in the state are eligible to participate in the demonstration if they are attributed to a participating provider. Exceptions are noted in the Request for Proposals (RFP) released by the Department of Human Services (DHS) and include blind or disabled Medicaid beneficiaries who are dually eligible for Medicare and beneficiaries receiving Medicaid benefits on a medical spend down basis.

Provider population: Providers who apply to participate in the demonstration must be enrolled Medicaid providers meeting criteria established in the RFP. Participating health care delivery systems (HCDSs) need not compel all of their providers to participate, particularly when the HCDS uses different care models in different locations around the state; the scope of the demonstration may be limited to sub-segments of clinics and systems that have specific models of care in some locations but not others.

Attribution: The RFP for the demonstration specifies that a preliminary population will be determined for each HCDS at the beginning of the performance period. At the end of the performance period, the attribution population will be re-calculated for accountability purposes. Attribution will be determined using a hierarchical process (based first on participant enrollment in a certified Health Care Home) described in the RFP. Answers from the DHS to questions submitted on the RFP establish that a minimum threshold of enrollment will be set for inclusion in the attribution model and there will not be geographic limits on enrollee attribution.

Scope of Services: Health care delivery systems (HCDSs) participating in the demonstration will be responsible for the total cost of care of their Medicaid patient populations participating in the demonstration. A DHS memorandum on definitions of total cost of care identified criteria for the inclusion of services in the definition of total cost of care:

Services provided by the primary care entities and other providers within the HCDS demonstration;

Services whose utilization would reasonably and significantly be affected by the coordination of care envisioned by this demonstration; and

Services that may have otherwise been included by the criteria listed above, but whose provision would provide value primarily beyond of the calculation of total cost of care have been excluded (e.g. respite care and long term acute hospital).

Specific procedure/revenue codes for included services were provided in a table released by the DHS.

Under the Minnesota Accountable Health Model, the state’s federally funded State Innovation Model to expand upon the HCDS Demonstration, the state will expand the scope of services to include mental health and long-term supports and services.

Patient Population: Each organization applying for certification as an Accountable Care Organization (ACO) must cover “a municipality or defined geographic area in which no fewer than 5,000 Medicaid recipients reside.” All Medicaid beneficiaries within an ACO’s defined geographic range are eligible to receive services from the ACO, though Medicaid beneficiaries may seek care outside of the ACO.

Scope of Services:P.L. 2011, Ch. 114 does not identify a scope of services that ACOs must include. However, the state’s approved 1115 waiver request to CMS specifies that ACOs will provide access to all services available under the State Plan. ACOs are expected to be integrated into their communities so that they can assist in coordinating community-based services for enrollees. Regulations issued in 2013 specify that the demonstration’s objectives include increasing access to primary care, behavioral health care, pharmaceuticals and dental care.

Provider population: ACOs are required to obtain the support of all general hospitals in the designated area, at least 75 percent of the primary care providers in the designated area, and at least four qualified behavioral health providers in the designated area (including at least one Department of Human Services-licensed mental health program and one Department-licensed substance abuse program).

Scope of Services: The statute does not specifically define the “array of services” that accountable care organizations (ACOs) will deliver. However, the statute is clear that primary care will be a critical component of the services offered by ACOs.

Patient Population: A definition of the population proposed to be served by an ACO, which may includes references to geographic area and patient characteristics, will be promulgated by the New York Department of Health in forthcoming regulations.

New York’s ACO law, NYS Public Health Code Article 29-E, calls for the convening of a workgroup by the Department of Health that will develop a proposal whereby an ACO—instead of a managed care plan—may serve Medicaid or Family Health plus enrollees who are required to participate in managed care.

Provider Population: The law does not limit which licensed health care providers may apply for certification as an ACO. It does, however, establish that ACOs shall use their best efforts to include any willing Federally Qualified Health Centers (FQHCs) among their participants, provided the FQHCs serve the area and population served by the ACO.

Population: Nearly all Oregon Health Plan enrollees, including Medicaid beneficiaries who are dually eligible for Medicare will be enrolled in Coordinated Care Organizations (CCO)s. The only Oregon Health Plan enrollees not subject to mandatory enrollment requirements are: noncitizens, American Indians/Alaska Natives, dual eligibles enrolled in a PACE program, enrollees who receive an exemption, and individuals who reside in an area not served by a CCO.

Under the State Innovation Model grant received by Oregon in early 2013, the model will be expanded beyond the Oregon Health Plan to public employees covered through the Public Employees Benefit Board, Medicare for dual eligibles, and commercial payers.

Scope of services: CCOs are responsible for integrating and coordinating physical, mental, behavioral and dental health care for enrollees. Oregon Department of Human Services Medicaid-funded long-term care services will not be provided by CCOs.

Attribution:Administrative rules governing the project stipulate that Oregon Health Plan beneficiaries choose the Coordinated Care Organization into which they would like to enroll. Beneficiaries that fail to choose a CCO will be assigned to a CCO that is open for enrollment, services the county in which the beneficiary resides, and has practitioners located within the community-standard distance for average travel time for the beneficiary.

Scope of services: The health care services for which health care collaboratives (HCCs) have responsibility is defined broadly in SB 7 as “services provided by a physician or health care provider to prevent, alleviate, cure, or heal human illness or injury.” The legislation explicitly notes that this includes pharmaceutical, medical, chiropractic, dental, and hospital care.

Eligible provider population: The statute does not place restrictions on physicians and health care providers licensed in the state of Texas from voluntarily joining HCCs. It does specify that an HCC may not prohibit a physician or other provider, as a condition of participating in that HCC, from participating in another HCC.

Aside from broad requirements for certification by the Texas Department of Insurance (described in the “Criteria for Participation” section), many of the details of HCC arrangements, including attribution and eligible patient populations, will be determined in contracts between HCCs and interested public and private payers. SB 7 provides the legal framework by which physicians and other providers can form new entities—specified in the legislation as having “all powers of a partnership, association, corporation, or limited liability company”—that can pursue more integrated delivery models and potentially assume more accountability for patient populations.

Scope of Services: Utah’s Accountable Care Organization (ACO) contracts would include inpatient hospital, outpatient hospital, physician services and other ancillary services, as well as pharmacy benefits. ACOs would not be responsible for mental health services, substance abuse treatment services, nursing facilities, or transportation.

Eligible Patient Population: All Medicaid beneficiaries are eligible for the ACOs, except for those in a nursing or inpatient facility.

Enrollment: Reflecting the program’s roots in managed care, Medicaid enrollees will choose an ACO contractor who will be responsible for the costs and quality of the care provided to them. Utah currently has mandatory enrollment in managed care plans in its four most populous counties, and the state proposes to implement the ACO contract model in those same four counties. Those who do not choose will be assigned and attributed to an ACO.

Patient population: All Medicaid beneficiaries that fall into one of the following “super eligibility categories” are eligible for assignment to a Medicaid accountable care organization (ACO) under the Medicaid Shared Savings Program: aged, blind or disabled adults who are not eligible for Medicare; blind or disabled children who are not eligible for Medicare; general adult; new adult; general child; and SCHIP child.

Attribution: Claims for specified CPT codes are analyzed for Medicaid beneficiaries falling into one of the super eligibility categories identified above who were enrolled for the entire 12 month look back period (the most recent 12 months for which claims are available). Beneficiaries are assigned to the practice where he or she had the greatest number of qualifying claims. Beneficiaries without claims experience are assigned to the primary care provider they have selected or to whom they have been auto-assigned.

Covered services: Medicaid ACOs will be responsible for Medicaid-covered services. Unlike ACOs supported by other payers, Medicaid ACOs will be responsible for spending on prescription medications; dental benefits; transportation; waiver services; mental health and substance abuse services; and services administered through the state’s Department of Education.

Authority refers to the specific source (e.g. legislation, executive office, cabinet or Medicaid agency) of the model’s authorization. This category also includes regulatory adjustments (e.g. changes to licensure requirements or data confidentiality rules) made by states to facilitate accountable care models.

Act 2013-261 became law in June 2013. This legislation calls for Alabama to be divided into regions and that a community-led network coordinates the health care of Medicaid patients in each region, with networks ultimately bearing the risks of contracting with the state of Alabama.

Alabama’s Medicaid agency is seeking an 1115 Waiver from CMS to allow for the implementation of the Regional Care Organizations.

The California Public Employees’ Retirement System (CalPERS) Board of Administration has long-standing authority under state law to contract with health insurance carriers to secure health benefit plans for its enrollees.

The Care Coordination Innovations Project is an initiative within the Illinois Department of Healthcare and Family Services to meet a legislative mandate that 50 percent of Medicaid beneficiaries be enrolled in coordinated care by 2015. This mandate—and the definition of “coordinated care”—was passed as part of Public Act 096-1501 in 2011.

The Centers for Medicare & Medicaid Services approved a State Plan Amendment to implement Coordinated Care Networks as part of a new Medicaid managed care program, Bayou Health. The State Plan Amendment took effect on February 1, 2012.

Chapter 224 of the Acts of 2012 establish a new state agency—known as the Health Policy Commissioner—in the Massachusetts Executive Office of Administration & Finance. The Commission is an independent public entity not subject to supervision or control by other executive offices or departments in Massachusetts. This Commission is granted authority to certify accountable care organizations (ACOs) and responsibility for oversight and monitoring of the ACOs.

In 2010, the Minnesota Legislature passed a bill (Minnesota Statutes § 256B.0755) requiring that the Commissioner of Human Services “develop and authorize a demonstration project to test alternative and innovative health care delivery systems, including accountable care organizations that provide services to a specified patient population for an agreed-upon total cost of care or risk/gain sharing payment arrangement.”

The Department of Human Services released a Request for Proposals from Health Care Delivery Systems (HCDSs) in the state in September 2011.

Minnesota received federal approval to implement the demonstration’s payment reforms under its Medicaid state plan in August 2012.

The New Jersey Medicaid Accountable Care Organization (ACO) Demonstration Project was authorized by the passage of P.L. 2011, Ch. 114. The statute specifies that the New Jersey Department of Human Services will establish the demonstration in consultation with the state’s Department of Health and Senior Services.

In the authorizing legislation, New Jersey’s legislature announced its intent to “exempt activities undertaken pursuant to the Medicaid ACO Demonstration Project that might otherwise be constrained by State antitrust laws and to provide immunity for such activities from federal antitrust laws through the state action immunity doctrine.”

In early October 2012, the Centers for Medicare & Medicaid Services approved New Jersey’s Comprehensive Medicaid Waiver, an 1115 demonstration waiver. The delivery system reforms covered in the waiver include the Medicaid Accountable Care Organization Demonstration Project.

The Oregon Integrated and Coordinated Health Care Delivery System was authorized by the Oregon legislature in 2011 through House Bill 3650. A second piece of legislation passed in 2012, SB 1580, approved follow-up proposals for Coordinated Care Organization qualification criteria and global budgeting processes developed by the Oregon Health Authority.

Section 15 of House Bill 3650 declared the Oregon Legislature’s intent to exempt CCOs from state antitrust laws, and to provide immunity from federal antitrust laws through the state action doctrine.

Oregon submitted to the Centers for Medicare & Medicaid Services a Request for Waiver Amendment to the 1115 Demonstration Waiver under which the Oregon Health Plan operates. The state requested a three-year extension of the waiver through October 31, 2016 and sought to maintain authorities included in its existing waiver, such as the authority to contract with managed care entities and to mandatorily enroll and auto-enroll individuals within managed care. The waiver request was approved in July 2012.

The development and certification of health care collaboratives (HCCs) was authorized by the Texas legislature via SB 7.

In addition to certification by the Texas Department of Insurance, potential HCCs must have their applications reviewed by the Attorney General of the state to verify that the collaborative will not likely reduce competition in the market for physician, hospital, or ancillary services and that the pro-competitive benefits of proposed HCCs outweigh the anticompetitive effects of increased market power.

SB 7 specified that certified HCC would be provided immunity from federal antitrust laws through the state action doctrine.

Utah is pursuing Accountable Care Organizations (ACOs) in Medicaid under the mandate to introduce new payment methodologies into Medicaid established by SB 180 in 2011.

The state originally included its proposal to convert existing managed care contracts into ACO contracts in the Payment & Service Delivery Reform Proposal for an 1115 Demonstration waiver it submitted to CMS in June 2011; this waiver was submitted in accordance with a statutory requirement included in SB 180. While CMS denied this waiver request, it expressed support for the ACO model proposed by the state. The state sought to amend its existing 1915(b) managed care waiver to incorporate the ACO contracting approach.

While Vermont has authority under an existing 1115 Demonstration waiver to implement a shared savings ACO in Medicaid, the state intends to submit a Medicaid State Plan Amendment for its Shared Savings Program.

Governance refers to the structures by which policy decisions around the accountable care model are made, and the specific stakeholders (including patients and community stakeholders) who assume responsibility for the project.

The Alabama Medicaid Agency is responsible for the development and oversight of the Regional Care Organization (RCO) program. RCOs would be largely governed by provider organizations that agree to share in the risk in a particular region of the state. Because they are provider-based organizations, the state would establish criteria and oversight procedures that will be managed within the Medicaid Agency (separate and apart from traditional insurers). The state will have the power to approve governing board members and to approve the selection process for RCO advisory committees.

Act 2013-261 requires that RCOs have a governing board of directors which includes 12 members will represent risk-bearing participants in the RCO (i.e. via contributing cash, capital, or other assets to the RCO) and 8 members representing other stakeholders. Of these eight members there will be:

5 medical professionals who provide care to Medicaid beneficiaries in a region served by a RCO (consisting of 3 Primary Care physicians, 1 Optometrist, 1 Pharmacist)

3 Community representatives, including

The chair of citizens advisory committee

An elected citizens’ advisory committee member

A business executive nominated by Chamber of Commerce in the region

Each RCO will have a Citizens’ Advisory Committee (at least 20% of members must be Medicaid beneficiaries).

The Arkansas Department of Human Services (which oversees Arkansas Medicaid) partnered with two large private payers, Arkansas Blue Cross and Blue Shield and Arkansas QualChoice, to form the Arkansas Care Payment Improvement Initiative. This group worked with providers, health administrators, patients and advocacy groups to design the payment reform that has begun to be put into effect. For more information, visit the state’s archive for this initiative.

The California Public Employees’ Retirement System (CalPERS) accountable care organization (ACO) pilot utilizes a shared governance model based on a Pilot Board. The board includes members of the executive leadership of the payer and provider organizations involved in the pilot: Blue Shield of California, Dignity Health, and Hill Physicians Medical Group.

A senior-level ACO Core Team made up of the pilot partners’ clinical, financial, and operational leadership provide day-to-day direction to the project.

The Department of Health Care Policy & Financing has developed an ACC Program Improvement Advisory Committee—representing RCCO staff, Primary Care Medical Providers, other provider groups, clients and families, and Department staff—to provide guidance and make recommendations for improvements in the ACC program.

The Accountable Healthcare Alliance of Rural Oahu (AHARO) serves as a contracting arm for three Federally Qualified Community Health Centers (FQHCs): the Koolauloa Community Health and Wellness Center, Waimanalo Health Center, and Waianae Coast Comprehensive Health Center. AHARO was established via an interagency agreement and answers to the three community-elected governing boards of the participating FQHCs.

An Accountable Care Entities (ACE) is defined as “An organization comprised of and governed by its participating providers, with a legally responsible lead entity, that is accountable for the quality, cost, and overall care of its Enrollees.”

Care Coordination Entities (CCEs) are collaborations of community providers and community agencies. Groups of providers that wish to become a CCE may create a new corporate entity or they may designate a lead entity to serve as the legal entity responsible for executing the CCE contract with the state.

Managed Care Community Networks (MCCNs) are entities that are owned, operated, or governed by health care providers; MCCNs must submit their articles of incorporation and by-laws with their application.

Each organization works under contract with the Illinois Department of Healthcare and Family Services.

Under a draft accountable care organization (ACO) agreement released by Iowa Medicaid, an ACO must possess the corporate resources and structure necessary to perform its responsibilities under the agreement and successfully implement and operate the ACO. ACOs must enter into written agreements or contracts with the patient managers (PMs).

ACOs must also established a governing body with responsibility for setting policy, developing and implementing a model of care, establishing best practices, setting and monitoring quality goals, and assessing PM performance and addressing deficiencies. The ACO must also demonstrate meaningful involvement of a Chief Medical Officer and PMs in the governance structure.

The agreement also stipulates that the ACO shall have a consumer advisory board that meets regularly and advises on ACO policies and programs including cultural competency, outreach plans, member education materials, prevention programs, member satisfaction surveys, and quality improvement programs.

Requirements for the makeup of the coordinated care network shared savings (CCN-S) entities are not specified, but the Request for Proposals released by the Louisiana Department of Health and Hospitals establishes that on-site readiness reviews of the CCN-S will focus on the performance of the governing body, among other areas.

The Maine Department of Health and Human Services released a Request for Applications (RFA) for its Accountable Communities initiative in October 2013. The RFA clarified that while the Accountable Community need not be an incorporated entity, each Accountable Community must establish a governance structure that is responsible for oversight and strategic direction of the Accountable Community and it must designate a Lead Entity. The Lead Entity must contract with all providers participating in the Accountable Community and the Lead Entity is responsible for receiving and distributing shared savings payments (or making shared loss payments to the Department of Health and Human Services).

Accountable care organizations (ACOs) are required by the Chapter 224 of the Acts of 2012 to have a governance structure that includes an administrative officer, a medical officer, and patient or consumer representation. They must be organized as a separate legal entity from the ACO participants.

The authorizing legislation, P.L. 2011, Ch. 114, states that any organization applying for certification as an Accountable Care Organization (ACO) must have a governing board which includes:

“Individuals representing the interests of: health care providers, including, but not limited to, general hospitals, clinics, private practice offices, physicians, behavioral health care providers, and dentists; patients; and other social service agencies or organizations located in the designated area; and

“Voting representation from at least two consumer organizations capable of advocating on behalf of patients residing within the designated area of the ACO. At least one of the organizations shall have extensive leadership involvement by individuals residing within the designated area of the ACO, and shall have a physical location within the designated area. Additionally, at least one of the individuals representing a consumer organization shall be an individual who resides within the designated area served by the ACO.”

Organizations that apply for certification as ACOs are required to have board representation that includes representatives of local hospitals, physicians, behavioral health care providers, and dentists.

Statute requires that organizations applying to act as ACOs be “organized with the voluntary support of local general hospitals, clinics, pharmacies, health centers, qualified primary care and behavioral health care providers, and public health and social services agencies.”

New York’s ACO law, NYS Public Health Code Article 29-E, requires that accountable care organizations (ACOs) provide for meaningful participation in the composition and control of the ACO’s governing body for ACO participants or designated representatives. ACO governing bodies must have at least one representative from each of the following groups:

Recipients of Medicaid, Family Health Plus, or Child Health Plus;

Persons with other health coverage; and

Persons who do not have health coverage.

ACO participants must hold at least 75 percent control of the ACO’s governing body. Further detail on ACO governance requirements will be issued in forthcoming regulations from the Department of Health.

Coordinated Care Organizations must ensure their governance structure makeup reflects community needs and supports the goals of health care transformation and meets governance structure criteria from ORS 414.625. The law requires that each CCO’s governance structure include a majority interest consisting of the persons that share financial risk of the organization. Major components of the of the health care delivery system and the community at large must also be represented.

CCOs are also required to convene regular meetings of community advisory councils (CACs) to obtain community perspectives. These councils include representatives of the community and of county government, but with consumers making up a majority of the membership.

Health care collaboratives (HCCs) are required by SB 7 to be governed by a board of directors whose members are elected by physicians and health care providers who participate in the HCC. If all participants in the HCC are physicians, each member of the board must be a physician. If the HCC consists of physicians and other providers, there must be an equal number of physician and health care provider representatives on the board.

The board of directors of an HCC is responsible for establishing a compensation advisory committee that develops recommendations regarding charges, fees, payments, distributions, or other compensation assessed for health care services provided by physicians or other providers participating in the HCC.

Governance standards for Vermont’s Medicaid Shared Savings Program (SSP) released in 2013 mirror the requirements of the federal Medicare Shared Savings Program. The state requires that accountable care organizations (ACOs) establish and maintain a governing body, separate and unique to the ACO (and not the governing body of any ACO participant) with adequate authority to execute the statutory functions of an ACO.

Participants in the governing body must be representative of practitioners participating in the ACO, include a Medicaid beneficiary served by the ACO, and 75 percent of the governing board must be chosen by ACO participants.

The SSP standards also require that ACOs have a leadership and management structure that includes clinical and administrative systems.

Criteria for participation in the accountable care activity include specific requirements set forth by the state in regulations, requests for proposals, managed care contracts, and other official policy statements. This includes patient protection requirements around notification and grievance resolution.

Act 2013-261 requires the Medicaid agency to establish by rule the criteria for certification of Regional Care Organizations (RCOs).

Since RCOs will provide Medicaid services to Medicaid enrollees directly or by contract with other providers, the certification standards will include service delivery network requirements: each RCO will be required to establish an adequate medical service delivery network as determined by the Medicaid agency. An alternate care provider contracting with Medicaid shall also establish such a network.

A Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC) or a clinic or other group practice with a focus on primary care, general practice, internal medicine, pediatrics, geriatrics, or obstetrics and gynecology; OR

An individual physician, advanced practice nurse or physician assistant with a focus on primary care, general practice, internal medicine, pediatrics, geriatrics, or obstetrics and gynecology

Furthermore, Primary Care Medical Providers must commit to nine additional principles that ensure care is patient/family-centered; whole-person oriented and comprehensive; coordinated and integrated; provided in partnership with the patient and promotes patient self-management; outcomes-focused; consistently provided by the same provider as often as possible so a trusting relationship can develop; and provided in a culturally competent and linguistically sensitive manner.

Participation in the Accountable Healthcare Alliance of Rural Oahu (AHARO) is currently limited to the three Federally Qualified Health Centers that established it in partnership with 2 Medicaid managed care plans: Koolauloa Community Health and Wellness Center, Waimanalo Health Center, and Waianae Coast Comprehensive Health Center.

Under the initial solicitation for proposals under the Care Coordination Innovations Project, organizations bidding to become Care Coordination Entities (CCEs) or Managed Care Community Networks (MCCNs) must:

Be able to facilitate care between hospitals and PCPs, and among hospitals, mental health Providers, substance abuse Providers, and PCPs

Demonstrate an adequate medical home network

Meet requirements in Section 2703 of the Affordable Care Act (ACA), if the CCE or MCCN plans to implement the Health Homes Option in Section 2703 of the ACA

Describe their electronic capabilities and their planned use of health information technology in coordinating care

Describe how their care coordination model is sensitive to the culture and specific needs of the populations they propose to serve

A draft accountable care organization (ACO) agreement released by Iowa Medicaid clarified that ACOs must be active Iowa Medicaid providers. They must also be able to demonstrate an integrated delivery system and share clinical information in a timely manner; and implement a model of care and financial management structure that promotes provider accountability, quality improvement, and improved health outcomes.

Among other responsibilities for ACOs that wish to participate in the Wellness Plan are that they must:

Securely pass clinical information among their patient managers (PMs) to aggregate and analyze data to coordinate care, utilizing both Direct Messaging and query capabilities as available

Work with the Department of Human Services to use Iowa Health Information Network capabilities to regularly exchange Admission Discharge Transfer data no later than July 1, 2015

Develop relationships with providers that are not ACO PMs and with community resources in its service area, and have a plan for coordinating behavioral health and physical health services and a plan for coordinating and partnering with community-based organizations to further PM outreach capabilities

State regulations require that a Medicaid-participating entity operating under the coordinated care network shared savings (CCN-S) model be a successful bidder, awarded a contract, and pass a readiness review. A CCN-S must:

meet the definition of a primary care case manager in accordance with federal regulations;

be a legal entity domiciled in Louisiana and registered with the Louisiana Secretary of State’s Office to do business in the state;

have the capability to pre-process claims (with the exception of carved-out services) and transfer data to the department’s fiscal intermediary or have a contract with an entity to perform these functions;

provide financial reports as requested by the department;

post a surety bond for an amount specified by the department for the at-risk portion of the enhanced care management fee;

post a performance bond for an amount specified by the department;

not have an actual or perceived conflict of interest that, in the discretion of the department, would interfere or give the appearance of possibly interfering with its duties and obligations under this Rule, the contract and any and all appropriate guides

and have network capacity to enroll a minimum of 75,000 Medicaid and LaCHIP eligibles into the network in each DHH designated geographic service area.

Accountable Communities will be required to serve a minimum number of MaineCare (Medicaid) members (the minimum number has not yet been determined). They must include MaineCare-enrolled providers. Accountable Communities must deliver primary care services and directly deliver or commit to coordinate with specialty providers, including behavioral health for non-integrated practices, and all hospitals in the proposed service area.

Accountable Communities will also be required to commit to:

Integration of physical and behavioral health

Practice and system transformation

Inclusion of patients and families in leadership roles and as partners in care and partners in organizational quality improvement activities

Developing formal and informal partnerships with community organizations, social service agencies, local government, etc.

The Department of Health and Human Services has proposed to align member protection requirements with the Medicare Shared Savings Program. Providers participating in an Accountable Community would be required to:

Post signs indicating participation in Accountable Communities in settings where primary care services are provided, and

Make available standardized written notices in plain language developed by the Department of Health and Human Services notifying members of the provider’s participation in Accountable Communities and the potential for MaineCare to share member identifiable data with the Accountable Community

The independent Health Policy Commissioner established by Chapter 224 of the Acts of 2012 is charged with developing certification standards for accountable care organizations (ACOs). While granting the Commission latitude to establish additional standards, the statute establishes twenty criteria for certification, including that certified ACOs must:

Have functional capabilities to coordinate care financial payments among providers

Have significant implementation of interoperable health information technology for the purposes of care delivery coordination and population management

Engage patients in shared decision-making, including on palliative and long-term care services and supports.

Provider organizations will use a common application form to apply to become ACOs and can be certified for a renewable term of up to 2 years.

The legislation established that the “purpose of the ACO certification process shall be to encourage the adoption of integrated delivery care systems in the Commonwealth for the purpose of cost containment, quality improvement and patient protection.”
The Commissioner is directed to incorporate models and practices that are funded by the state’s Healthcare Payment Reform Fund and found to be successful into the ACO certification standards it develops.

Criteria for providers wishing to participate in the demonstration as a health care delivery system (HCDS) were specified in the RFP released by the Department of Human Services. These criteria require participating providers to:

Deliver the full scope of primary care services and either deliver specialty services or demonstrate the ability to coordinate with specialty providers and hospitals

Be enrolled as Medicaid providers

Demonstrate how the HCDS will affect the total cost of care of its Medicaid participants

Incorporate in the care delivery model formal and informal partnerships with community organizations, social service agencies, counties, etc.

Engage patients and families as partners in the care they receive

A participating HCDS must have a minimum assigned Medicaid population of 1,000 members.

Applicants must be formed as a nonprofit corporation pursuant to New Jersey state law;

Applicants must have a governing board that includes a range of provider, social service, and consumer advocacy representatives (see Governance, above);

Applicants must have the support of all general hospitals located in the designated area served by the ACO, no fewer than 75% of the qualified primary care providers located in the designated area, and at least four qualified behavioral health care providers in the designated area;

Applicants must have a process for receipt of gainsharing payments from the state and any voluntarily participating Medicaid MCOs;

Applicants must have a process for engaging members of the community and for receiving public comments with respect to gainsharing plans;

Applicants must have a commitment to become accountable for the health outcomes, quality, cost, and access to care of Medicaid recipients residing in the designated area for a period of at least three years; and

Applicants must have a commitment to ensuring the use of electronic prescribing and electronic medical records by health care providers in the designated area.

Accountable care organizations (ACOs) must be issued a certificate of authority by the Commissioner of the Department of Health. The Commissioner is authorized to issue certificates through December 31, 2016. New York’s ACO law NYS Public Health Code Article 29-E specifies a number of areas that will be addressed by the ACO regulations, including:

Adequacy of an ACO’s network of participating providers, including primary care providers

Mechanisms by which an ACO will provide, manage, and coordinate quality health care for its patients, including the potential incorporation of patient-centered medical home standards into the ACO certification process

The law also allows the Department of Health to create an expedited review process for certification of organizations approved by the Centers for Medicare & Medicaid Services to participate in the Medicare Shared Savings Program. These ACOs would be certified as “Medicare-only ACOs.”

Engaging community members and health care providers in improving the health of the community and addressing regional, cultural, socioeconomic and racial disparities in health care that exist among the entity’s enrollees and the entity’s community

Health care collaboratives (HCCs) are defined by SB 7 as entities that arrange for medical and health care services for insurers and other payers. They consist of physicians and may include other health care providers and/or insurers.

The statute establishes that entities seeking certification as HCCs must demonstrate that they have a sufficient number of primary care physicians in the HCC’s service area, they must show that they have sufficient working capital and reserves to operate the collaborative, and they must pass an antitrust review by the Office of the Attorney General. More details about these requirements were established in regulations proposed by the Texas Department of Insurance in September 2012.

Each HCC must also show the “willingness and potential ability” to ensure their approach to service delivery:

HCCs must also satisfy the Insurance Commissioner that they have processes in place:

That contain health care costs without jeopardizing the quality of patient care

To develop, compile, and report statistics on performance measures relating to the quality and cost of health care services, the pattern of utilization of services, and the availability and accessibility of services;

Medicaid-participating providers that form an organization meeting the governance standards may participate in the Medicaid Shared Savings Program. Following the lead of commercial accountable care organization (ACO) pilots in the state, Vermont’s Medicaid Shared Savings Program standards may require ACOs to develop a defined and coordinated strategy for care management.

As described in the 1115 Waiver Concept Paper, this initiative would utilize a payment model that includes capitation with care management payments (the transition period could include fee-for-service).

The state will reform its payment methodologies to implement value-based purchasing strategies (the state offers the example of transitioning hospitals from per diem payments to All Patient Refined Diagnosis Related Groups). RCOs would be expected to use this methodology in establishing contracts with providers.

The state also proposes to enhance coverage or modify reimbursement for a number of services to encourage capacity development, potentially including care coordination fees to providers to cover necessary care coordination services that are not directly reimbursable under the current benefit structure.

As stated in the initiative’s Planning Principles, Medicaid will establish a floor for applicable provider payments for all regions, including out-of-region contracts.

Providers are eligible for risk- and gain-sharing based on average cost of care per-episode, assessed yearly based on claims data. Payers are using claims data to assess historical average per-episode costs for each episode type, and identifying thresholds that they believe will maximize provider incentives to provide high quality, cost effective care. For each episode, payers will identify three ranges (see slide 18) against which to assess principal accountable providers’ (PAPs’) average per-episode costs and determine provider eligibility for risk- and gain-sharing:

Acceptable: There will be no change in payment to providers whose average per-episode costs fall within this range.

Commendable: PAPs will receive incentive payments equal to 50% of average per-episode savings below this threshold if they achieve quality standards.

Gain-sharing is dependent on achievement of “must pass” quality indicators which differ for each episode type; providers who achieve commendable average per-episode costs but fail to achieve these standards will not receive shared savings payments. However, providers who fail to fully report or who do not achieve these standards remain eligible for risk-sharing. A lower gain-sharing limit for each episode and minimum quality requirements disincent under-treatment; stop-loss provisions provide some financial protection to PAPs whose costs are above the “unacceptable” threshold. Risk- and gain-sharing percentages are defined in provider policy manual updates proposed by Medicaid for upper respiratory infections, ADHD, and perinatal care episodes (proposed in June 2012) and for congestive heart failure and total joint replacement episodes (in September 2012).

Regulatory language proposed by Arkansas Medicaid in June 2012 provides more detail on each episode type, including exclusions and proposed payment thresholds, as well as Medicaid’s methodologies for calculating risk- and gain-sharing payments.

The California Public Employees’ Retirement System (CalPERS) accountable care organization (ACO) pilot relies on a hybrid of shared savings and global payment approaches: the pilot has a global spending target and offers shared risk and savings among Blue Shield and the participating providers, the hospital chain Dignity Health and Hill Physicians Medical Group. Blue Shield and the two provider organizations operate under a three-way per member per month budget; each shares the savings achieved under the target, and each bears financial risk for spending in excess of the target.

Risk was not even distributed among Blue Shield, Dignity Health, and Hill Physicians Medical Group for all services. Services were broken into broad "cost categories": facility costs (partner hospital, out-of-area non-partner hospital, and other non-partner hospital), professional costs, mental health costs, pharmacy costs, and ancillary costs. Each partner assumed greater risk for cost categories over which it had the most influence on per member per month costs.

However, the underlying reimbursement mechanisms for participating providers did not change during the pilot. The hospitals were still paid for services on a fee-for-service basis and the participating physician group was still paid on a capitated basis.

In the program’s expansion phase, RCCOs and Primary Care Medical Providers are eligible to receive incentive payments: initial incentive payments will be available for RCCOs and Primary Care Medical Providers that reduce emergency room visits, hospital re-admissions, and utilization of medical imaging. On July 1, 2013, a fourth indicator measuring well child visits was added to this list. PMPM payments to RCCOs and Primary Care Medical Providers will be reduced to $12 and $3 respectively, with $1 from each withheld to support incentive payments based on achievement of performance targets. The state hopes to incorporate a shared savings component at a later date as more beneficiaries enroll in the ACC program.

Legislation passed in June 2012, House Bill 12-1281, will also test innovative payment methodologies “that are designed to provide greater value while ensuring good health outcomes and client satisfaction.” In July 2012, RCCOs were invited to submit abstracts outlining proposed innovative payment methodologies to participate in the “Medicaid Payment Reform and Innovation Pilot Program.” Abstracts will be reviewed during the fall of 2012, and the Department plans to release formal proposal criteria by November 1, 2012. HB 12-1281 requires the state to select one or more proposals for piloting by July 1, 2013. See the state’s Payment Reform Initiative fact sheet for a complete timeline.

AHARO’s payment model uses a per member per month payment for medical home proficiency, as well as a $5 per member per month match from health plans for investment in health information technology and care coordination. Shared savings are built into the contracts with health plans, based on seven metrics. AHARO receives 50-75% of the savings, depending on the relative health center and health plan performance on financial metrics and accountability measures.

A care coordination fee, paid on a per member per month basis for each population in its care coordination model. A percentage of the fees will be withheld, contingent upon the CCE meeting quality measure targets.

A shared savings model that makes the CCE eligible for up to 50 percent of annual savings below a projected cost of care baseline, provided quality targets are met.

An “interagency payment flexibility proposal” option, by which CCEs are encouraged to develop innovative payment methodologies, which may include new reimbursement methods like bundled payments or payments for episodes of care.

CCEs may choose more than one of the reimbursement options. CCEs may also propose alternative reimbursement methodologies to fee-for-service for medical services.

Managed Care Community Networks (MCCNs) operate under a capitated payment structure. Portions of the capitation rate are withheld and paid based on the MCCN’s performance in meetings quality measure targets.

Accountable Care Entities will receive care coordination payments and receive shared savings for the first 18 months of their operation. For months 19 through 36, ACEs will transition to pre-paid capitation with pay-for-performance incentives. Beginning in the fourth year of operations, CCEs will receive full risk-based capitation payments.

In the first year of the operation of an accountable care organization (ACO), primary care physicians in it will initially be paid on a fee-for-service basis, and they will receive a care coordination payment for managing referrals and coordinating care. The ACO will receive bonus payment according to the performance targets and methodology detailed in a Value Index Score Medical Home Bonus Document.

A $10.00 per year per member that received aphysical exam Physical Exam Bonus. Providers qualify for the bonus if at least 85 percent of members who have been attributed for at least six months have received a physical exam during the Performance Year.

A Medical Home Bonus of up to $4.00 per member per month (PMPM) based on performance in meeting measures aligned with core attributes of good primary care: (1) person-focused care; (2) first contact with the health care system; (3) comprehensive, coordinated care and (4) transfer of information.

An ACO Incentive of an additional $4.00 PMPM for assisting in the transformation to a person centered delivery system. To receive this bonus, the ACO must provide: member education and outreach on the plan’s benefits, on adopting healthy behaviors, and on the premiums for which members might be responsible. ACOs must also provide resources to their patient managers that include collection and evaluation of health risk assessments, support in providing after-hours care, and establishing urgent care centers and supporting efforts in ongoing member outreach and education.

In subsequent years, ACOs will be subject to a risk-adjusted global budget with shared savings (and, within five years of the initial contract year, two-way risk sharing) based on quality performance.

Under a fee-for-service with coordinated care networks shared savings (CCN-S) model, the CCN-S receives monthly enhanced primary care case management fees, as well as lump sum savings payments if it is eligible. The CCN-S in turn reimburses primary care providers a monthly case management fee for each enrollee assigned to the primary care provider.

The state will establish a Per Capita Prepaid Benchmark (PCPB) based on the health risk for Medicaid enrollees in the CCN-S. Periodic reconciliations (for time periods covering at least 12 months of service) are performed by the Department of Health and Hospitals to determine total medical cost incurred by the CCN-S. If the CCN-S exceeds the PCPB, it will be required to refund to the state up to 50 percent of the total amount of enhanced primary care case management fees paid to the CCN-S during the performance period. The CCN-S is eligible to receive up to 60 percent of savings if the actual aggregate costs of authorized services, including enhanced primary care case management fees advanced, are less than the aggregate PCPB.

Due to federally mandated limitations under the Medicaid State Plan, shared savings will be limited to five percent of the actual aggregate costs including the enhanced primary care case management fees paid.

Accountable Communities that do not consist of integrated health systems will operate under a shared savings model. A target per member per month is identified for the Accountable Community based on risk-adjusted actuarial analysis of project costs. If the actual per member per month amounts is lower than the target amount, the savings are split between the state and the Accountable Community; the Accountable Community can share in a maximum of 50 percent of savings based on quality performance.

Accountable Communities that have capacity to assume risk will move toward a symmetric risk-sharing model over time: these Accountable Communities will be responsible for a portion of the loss associated with actual per member per month expenses that exceed the target PMPM. These Accountable Communities can share in up to 60 percent of savings (based on quality performance), but are held accountable for up to 5 percent of losses in year two and 10 percent of losses in year three.

The Department of Health and Human Services will cap the per member costs included in cost calculations for shared savings or penalties to protect Accountable Communities from being penalized for an abnormal distribution of catastrophic claims. Per enrollee costs are capped at:

$500,000 for large (5,000 or more attributed members) Accountable Communities

Additional payment reform models will also be phased in under the Accountable Communities Program as part of a continuum of payment reform. This continuum begins with shared savings, moves to shared savings plus risk, then to partial capitation models, and finally to global capitation.

Certified accountable care organizations (ACOs) will be required to receive reimbursements or compensation from alternative payment methodologies—defined as methods of payment not solely based on fee-for-service reimbursements—and they must be capable of coordinating financial payments among their providers. These alternative payment methodologies must be consistent with the adoption of payment incentives that improve quality and care coordination. The legislation specifies that these alternative payment methodologies may include, but are not limited to, shared savings arrangements, bundled payments, and global payments.

Standards for the alternative payment methodologies used to reimburse ACOs will be described in forthcoming regulations from the Health Policy Commission.

The Health Care Delivery Systems (HCDS) demonstration will use two payment models. Both models will set a risk-adjusted total cost of care target for participating HCDSs that is calculated using risk-adjusted fee-for-service or encounter claims. Participating providers continue to receive fee-for-service or managed care contracted payments, but each HCDS’s performance for all Medicaid enrollees attributed to it for the performance period will be compared to the total cost of care target. Savings will be shared between the HCDS and the state via a reconciliation payment that is disbursed annually, contingent upon performance on quality and patient experience indicators.

One payment model, the Virtual HCDS, is aimed at provider organizations including primary care providers and/or multi-specialty providers groups that are not formally integrated with a hospital or integrated system. This approach uses a shared savings model in which the difference between annual expected and actual realized total cost of care is distributed if savings are achieved.

The second payment model, the Integrated HCDS, applies to provider organizations that are integrated delivery systems providing a broad spectrum of outpatient and inpatient care as a common financial and organizational entity (serving 2,000 attributed Medicaid participants or more). This uses a shared risk model that builds toward two-way risk sharing over time.

In the Integrated HCDS model, gains above a minimum 2 percent performance threshold are shared equally between the state and the HCDS in Year 1. In Year 2 the HCDS assumes asymmetric downside risk (with a minimum 2:1 ratio of gain-sharing thresholds to loss-sharing thresholds) and in Year 3 the HCDS assumes symmetric risk-sharing thresholds.

As described in a DHS memorandum on catastrophic claim cap levels, the amount of a HCDS’ liability for catastrophic cases is limited by caps to the defined total cost of care that a provider organization can be accountable for. These caps are:

The New Jersey Department of Human Services will approve gainsharing plans submitted by applicant Accountable Care Organizations (ACOs) with input from the state’s Department of Health and Senior Services and assistance from Rutgers Center for State Health Policy. Gainsharing plans must promote “improvements in health outcomes and quality of care, as measured by objective benchmarks as well as patient experience of care; expanded access to primary and behavioral health care services; and the reduction of unnecessary and inefficient costs associated with care rendered to Medicaid recipients residing in the ACO’s designated area.”

Under the gainsharing plan, a percentage of the cost savings achieved by an ACO will be distributed to the ACO. P.L. 2011, Ch. 114 establishes that “Savings shall be calculated in accordance with a methodology that:

Identifies expenditures per recipient by the Medicaid fee-for-service program during the benchmark period, adjusted for characteristics of recipients and local conditions that predict future Medicaid spending but are not amenable to the care coordination or management activities of an ACO which shall serve as the benchmark payment calculation;

Compares the benchmark payment calculation to amounts paid by the Medicaid fee- for-service program for all such resident recipients during subsequent periods; and

Provides that the benchmark payment calculation shall remain fixed for a period of three years following approval of the gainsharing plan.”

Managed care organizations in the state may also choose to contract and establish a plan for gainsharing with ACOs participating in the Medicaid ACO pilot. Regulations issued by the Department of Human Services in April 2013 anticipate that ACOs may negotiate different savings allocations with different managed care organizations.

The 2013 regulations clarified that ACOs may seek to pursue shared savings in phases. They may focus the shared savings on a specific spending area (e.g. diabetes treatment) in the first year of the project, but by the end of the demonstration period the ACO’s gainsharing plan must identify savings for all Medicaid costs within the designated geographical area.

However, NYS Public Health Code Article 29-E provides that ACOs may enter into payment arrangements with one or more third-party payers to establish novel payment methodologies, including full or partial capitation. Payment arrangements must include provisions for the ACO to receive and distribute payments to participating providers, including incentive payments (which can include medical home payments). ACOs can have mechanisms in place to pool payments received by participating providers from third-party payers.

As described in the state’s 1115 waiver request narrative, Coordinated Care Organizations receive a fixed global budget from the state. These global budgets include:

A capitated per-member per-month portion for services formerly provided by physical health plans, mental health organizations and (in included) dental care organizations (alcohol/drug treatment services and dental coverage are optional for inclusion in CCOs until July 1, 2013 and July 1, 2014, respectively, at which point inclusion is required in the CCO benefit package);

CCO transformation incentive payments held outside of the capitated portion to 1) infrastructure for metric reporting and delivery system transformation efforts in year 1 of the global budgets, and 2) incentive for continual transformation and improvement through meeting both cost and health outcomes metrics; and

Medicare funding to blend with Medicaid funding to provide services to dual eligibles.

CCOs are expected to move beyond fee-for-service payment mechanisms for compensating health care services providers. CCO applicants must be able to demonstrate experience and capacity for “Developing and implementing alternative payment methodologies that are based on health care quality and improved health outcomes.” Alternative payment methodologies include, but are not limited to: shared savings arrangements, bundled payments, payments based on episodes, and payments based on a global budgeting system.

A Transformation Center will be formed under Oregon’s State Innovation Model Grant to provide technical assistance to promote alternate payment methodologies. The Center will offer implementation tools for a “start set” of promising payment models, which will include:

Health care collaboratives (HCCs) in Texas may contract with governmental or private entities for all or part of the cost of services provided or arranged by the collaborative. They can then distribute payments to participating physicians and health care providers in a manner approved by the board of directors.

HCCs can contract for, accept, and distribute payments from public or private payers based on fee-for-service or alternate payment methodologies, including:

Accountable Care Organizations (ACOs) would receive monthly, risk-adjusted capitated payments based on enrollment. The payments will consist of actuarially certified rates based on major categories of Medicaid eligibility and the severity of illness prevalent in the enrolled population. They would be responsible for delivering necessary and appropriate care, as well as demonstrating that quality of care and access to care are not suffering.

Organizations contracting as ACOs will be given flexibility to pursue innovative payment mechanisms among their networks of providers. According to the state’s proposal, “Rather than reimbursing providers based on the units of service delivered, the ACO would make payments for delivering the necessary care to a group of Medicaid enrollees for a specified period of time.”

The state distinguishes this arrangement from traditional managed care contracts by noting:

(1) that the ACO contract payments eliminate the incentives to provide excess care and

(2) the contracts will be maintained only if the ACO meets established quality and access criteria.

Under Track 1, ACOs will not agree to downside risk and their upside shared savings will be smaller than under Track 2. Under Track 2, ACOs will have a downside risk component in which they are required to repay Medicaid for shared losses. ACO will assume the following downside risk in each pilot program year :

Year 1: risk limited to 5.0% of total benchmark expenditures

Year 2: risk limited to 7.5% of total benchmark expenditures

Year 3: risk limited to 10.0% of total benchmark expenditures

For both tracks, the state will identify members who would have been attributed to the ACO in 2010, 2011, and 2012. Total expenditures for all services for each attributed member within a calendar year are trended and risk-adjusted to produce a blended per member per month expenditure value for each eligibility super category. The average per member per month spending across all super categories, weighted by member volume, is then calculated to produce a single historical benchmark.

Actual spending will be calculated to determine if the ACO has achieved savings or losses—beyond a minimum savings rate and minimum loss rate, respectively—relative to the historical benchmark.

For losses in excess of the minimum loss rate, an ACO participating in Track 2 is responsible for paying back a share of the losses. For savings in excess of the minimum savings rate, ACOs in both tracks are eligible for savings if they meet a minimum threshold for performance on a defined set of common measures to be used by all pilot-participating ACOs.

The ACO is assigned points based on its level of quality performance. Greater point scores result in the ACO receiving a larger percentage of the total shared savings payment for which it is eligible.

Support for infrastructure refers to a range of supports offered to accountable care projects by the state, including information technology, staff support, data feedback loops, and the convening of learning collaboratives.

Regional Care Organizations (RCOs) and Alabama’s Patient Care Networks would be required to leverage the health information exchange (HIE) infrastructure under development in Alabama, One Health Record™. To ensure better integration of the Medicaid providers into the larger health care marketplace, the health information exchange (HIE) would be the primary vehicle through which Medicaid providers share and access clinical information.

Providers affiliated with RCOs would be expected to use the standardized continuity of care record (CCD), which is currently under development and will be a component of the providers’ electronic health records. HIE will provide real-time access to data that will support providers in predicting, planning for, and intervening when necessary in a beneficiary’s care management plan. In the interim, the state has approved other web-based tools to facilitate the efficient exchange of medical information between physician offices and health care facilities.

In the state’s 1115 Waiver Concept paper, it proposes that RCOs would be eligible to receive reimbursement for certain upfront development and implementation costs, such as:

Joint governance models to support the ability for multiple providers to oversee and have responsibility for the RCO services provided to its members.

While the California Public Employees’ Retirement System (CalPERS) in its role as purchaser is not directly providing infrastructure supports to Blue Shield or the participating providers, the insurer and provider organizations have worked together to build the infrastructure for a better integrated system between them.

Development of CalPERS-specific utilization management through a coordinated operational infrastructure (e.g. earmarking nurses in the three organizations to coordinate timely sharing of information and developing a new integrated discharge planning process);

Elimination of unnecessary utilization and non-compliance through personalization population management;

Improvements to physician clinical and resource variation through quantitative analysis and targeted interventions;

Reductions in pharmacy costs and utilization through directed member outreach, drug purchasing and contracting strategies;

Facilitation of the rapid and efficient communication of patient medical information through information technology integration; and

The Statewide Data and Analytics Contractor provides RCCOs and Primary Care Medical Providers with access to profiles of individual clients based upon predictive modeling; identification of areas for clinical process improvement at the client, provider, and RCCO levels; and aggregate reporting of cost and utilization performance indicators.

The Accountable Healthcare Alliance of Rural Oahu (AHARO) has proposed the establishment of a $5 per member per month matching fund by Medicaid managed care organizations that would fund health information technology and care coordination activity.

AHARO is using a data exchange and data repository that combines information from electronic health records at participating health centers and those of the two Medicaid health plans to create real-time dashboards reflecting the status of performance by providers. Incentives are proposed linked to improved performance on selected metrics by each individual health care home.

The state has developed a matchmaking database to help potential collaborators to identify other entities that may be interested in participating in a Coordinated Care Entity (CCE) or Managed Health Care Network (MCCN).

The state may also advance a portion of the care coordination fees to fund start- up costs, such as investments in health information technology (HIT); advance payments made will be recouped from future care coordination payments on a negotiated schedule.

Accountable Care Entities (ACEs) are expected to build infrastructure (including HIT and data analytics) to support care management among providers participating in the ACE’s network.

Provide the ACO with periodic cost and utilization reports to enhance health care management and coordination that will support member education efforts, and allow primary care providers—known as patient managers (PMs)—to compare peer utilization levels.

Examine peer utilization and establish standards (through a managed health care advisory committee) for acceptable levels of utilization, consult and make recommendations for action on quality of care issues, and make recommendations for corrective action measures to take with PMs when quality deficiencies are identified.

Ensure that enrollments, disenrollments, requests for exception to policy, appeals, and access to the state’s fair hearing system are in compliance with state and federal laws and regulations.

Establish protocols for (1) PMs to use in authorization of medical services in routine, urgent, and emergent situations, (2) reviewing and acting upon utilization review reports, and (3) other procedures necessary for the administration of the Wellness Plan.

Provide tools and reports of the Iowa Wellness Plan members attributed to the PMs within the ACO (these tools will be expanded over time with input from the ACOs).

Provide PMs with a monthly report of Wellness members attributed to them.

Provide the ACO with a monthly report of all Wellness members attributed to the PMs within the ACO.

Each CCN-S is required to provide technical support and appropriate incentives to assist primary care practices with their transition to a patient-centered medical home model. The CCN-S is also required to facilitate the data interchange between the network and the department.

Continuing work and learning support around the development of value based insurance design

The MHMC’s Foundation, the lead agency for public reporting of quality information in the state, will continue to provide performance measurement and feedback to providers, employers, and insurers under this initiative.

For the innovation model, Maine’s health information exchange HealthInfoNet will provide several services, including emergency department notifications to community care teams, and capturing Health Homes clinical outcomes from electronic health records for reporting and analysis.

The independent Health Policy Commission will help accountable care organizations (ACOs) to identify best practices by creating a designation process for model ACOs. This designation will be granted to ACOs that meet standards of excellence for quality improvement, cost containment and patient protections.

The Commission will administer the state’s Healthcare Payment Reform Fund, which will allow health care entities to participate in a competitive process for incentives, grants, technical assistance, and evaluation assistance or partnerships to develop, implement, and evaluate promising models of health care payment and service delivery.

Data feedback to providers:. The Department of Human Services will make available to participating providers a variety of enrollee data to support care management. The enrollment and complexity indicators the DHS will report on are detailed in a memorandum from the department and include elements like:

Chronic condition counts;

Condition indicators;

Frailty flags; and

Mental illness flags.

Community Care Teams. Under the state’s State Innovation Model grant, three existing multidisciplinary, locally-based Community Care Teams will be expanded to support fifteen Accountable Communities for Health. They will leverage community partnerships to focus on including non-health care providers in the state’s accountable care organizations, integrating care, and building on the state’s patient-centered medical Health Care Home model.

Each Coordinated Care Organization is required by regulation to participate in a learning collaborative established (in ORS 442.210) by the Office for Oregon Health Policy and Research as part of the state’s patient-centered primary care home program.

Under its State Innovation Model award, Oregon plans to create a Transformation Center to support a statewide “Rapid Learning Health System” that facilitates the spread of the state’s model to other payers. A Patient-Centered Primary Care Home Technical Assistance Institute will reside under the Transformation Center is planned for launch in the fall of 2013.

An incentive pool for rewarding CCO performance on quality, access, and efficiency will be implemented by the middle of 2013.

The Oregon Health Authority’s Office of Health Analytics will support the Transformation Center that will be established under Oregon’s State Innovation Model grant. The Office of Health Analytics has access to health-related data sets containing claims or encounters, data on long-term services and supports outside of CCOs, surveys (including the Consumer Assessment of Healthcare Providers and Systems survey), the state’s All-Payer All-Claims database, and a Client Process Monitoring System that contains clinical information on mental health/chemical dependency services. The office will use this data to support the improving and targeting of services, performance measurement, and communication on performance.

A multi-payer claims dataset (VHCURES) that contains claims from public and private payers and has been mapped to key measures of utilization, expenditures and quality tracked by the Blueprint for Health;

A statewide health information exchange (VHIE) with capacity to produce care summaries and continuity of care documents (CCD), lab and other diagnostic reports, demographics related to admissions, discharges, and transfers and to query or pull clinical data from participating providers’ Electronic Health Record (EHR) systems;

A “central registry” that captures a defined set of clinical data from Vermont health care practices;

Trainers who work with individual provider sites to develop the data input capacity and quality controls necessary to produce reliable data sets for analysis and feedback.

The Medicaid Agency will create a quality assurance committee appointed by the Medicaid commissioner. Members of the committee will serve two year terms. At least 60 percent of the committee must be physicians who provide care to Medicaid beneficiaries served by Regional Care Organizations (RCOs).

In accordance with Act 2013-261, the committee will identify objective outcome and quality measures for ambulatory care, inpatient care, chemical dependency and mental health treatment, oral health care and all other services provided by RCOs. The quality measures must be consistent with existing state/national measures. The Medicaid Commission will incorporate these measures into RCO contracts. The committee will adopt outcome and quality measures annually and adjust measures to reflect:

The amount of the global budget for a RCO

Changes in membership of the organization

The organization’s cost for implementing outcome and quality measures

The community health assessment and the costs of the community health assessments conducted by the organization

The Medicaid Agency will evaluate the outcome/quality measures adopted by committee and will publish information by RCO on quality, cost, outcome and as well as other relevant information.

The Medicaid agency will publish aggregate-level public reports by RCO on:

Quality measures

Costs

Outcomes

Other information specified in the RCO contract that is necessary to evaluate the value of health services delivered by the RCO.

Providers are required to report on “to pass” quality indicators which differ for each episode type; providers who achieve commendable average per-episode costs but fail to achieve these standards will not receive shared savings payments. In addition, providers will report “to track” quality indicators

Providers will have access to individualized quarterly performance reports through the Provider Portal. Performance reports will include data on quality across episodes, cost effectiveness relative to cost thresholds and other providers, and the provider’s utilization patterns and cost drivers. Reports available through the Provider Portal will draw on claims data as well as clinical data entered into the Portal by PAPs.

Report contents are under development; more information regarding reports can be found here. Providers have access to quarterly reports during the initial preparatory period to gain comfort with this system and assess current performance.

Blue Shield of California commissioned the actuarial firm Milliman to evaluate the accountable care organization (ACO) pilot’s savings and performance during its first year (2010). The evaluation showed that health care costs for the California Public Employees’ Retirement System’s (CalPERS) members in the ACO pilot declined by 1.6 percent in 2010 relative to the 2009 baseline; at the same time, costs for CalPERS members not participating in the ACO rose by 9.9 percent in 2010 relative to the 2009 baseline. The pilot’s savings came from a mix of reductions in health care resource use by members and deceleration of the rate of increase of unit cost reimbursement.

While the evaluation looked at factors such as inpatient days and hospital readmissions, payment for the pilot is not specifically tied to a particular set of quality metrics. Instead, the participating parties have agreed that no cost containment initiatives expected to have a negative impact on quality would be implemented, and several quality improvement strategies and initiatives have been launched in association with the pilot. These include steps like educating and monitoring physicians on accepted protocols, developing presurgical checklists for patient calls prior to procedures, and defining and implementing evidence-based guidelines for surgeries in high-volume, high-cost hospital stays. The partners have also worked to develop adashboard of quality measurements to keep them apprised of how well they are performing.

The primary goals of Colorado’s Accountable Care Collaborative program are to improve health outcomes through a coordinated, client/family-centered system that proactively addresses clients health needs and control costs by reducing avoidable, duplicative, variable and inappropriate utilization. In the program’s first year (slide 13), the state will track utilization measures monthly and do quarterly cost savings analyses to track progress toward these goals. In subsequent years, the state plans to track utilization as well as quality and outcomes measures, and will assess stakeholder participation.According to the Accountable Care Collaborative Annual Report (FY2013-14) released by Colorado’s Department of Healthcare Policy and Financing, analysis of the ACC program to date has shown:

15-20% reduction for hospital readmissions and 25% reduction in high cost imaging services;

22% reduction in hospital admissions among ACC members with chronic obstructive pulmonary disease;

Lower rates of chronic health conditions (e.g., hypertension and diabetes) relative to clients not enrolled in the ACC Program;

A slower rate of emergency room utilization increase by ACC enrollees; and

$44 million gross, $6 million net reduction in total cost of care (cost avoidance) for clients enrolled in the ACC Program.

Providers participating in the Accountable Healthcare Alliance of Rural Oahu (AHARO) are evaluated on metrics developed as a part of the Pacific Innovation Collaborative (PIC) project. These metrics were negotiated with two Medicaid health plan partners and include measures with subsets of patients demonstrating co-morbidities to psychosocial conditions as well as metrics that measure access to primary care.
Practices participating in AHARO are further evaluated not only on NCQA patient-centered medical home standards but also on a set ofsupplemental “health care home” standards. These standards measure practices’ capacity along four dimensions:

Care enabling services,

Cultural proficiency,

Community involvement, and

Workforce and economic development.

AHARO has developed a set of performance standards for the Medicaid health plans that focus on the following capabilities:

Primary Care and Specialty Network Capability: designed to measure a plan’s ability to provide vertical networks of providers under contract and accessible to patients.

Claims Processing Capability: designed to measure the technical capabilities of a Plan’s claims adjudication effectiveness.

Health Care Home Model and Value Added Support: designed to measure the flexibility and support offered by the Plan to the medically underserved area-based health care home.

Aligned Incentives and Shared Savings: designed to assess the Pay For Performance and shared savings model with emphasis on transparent assessment of the relative value provided by health care home/payer partners.

Effectiveness and Efficiency Initiatives: designed to assess levels of cooperation in paperwork reduction and automation of processes while improving reporting quality.

Inpatient Management and Care Transition Management: designed to manage inpatient hospital stays and support effective care transition after discharge.

Appendices to the initial solicitation for proposals under the Care Coordination Innovations Project contain a number of quality measures that will be used to hold the provider-organized Care Coordination Entities (CCEs) and Managed Care Community Networks (MCCNs) accountable for the quality of care provided to enrollees. Payments under the risk-based payment models for CCEs and full capitation rates for the MCCNs will be tied to seven of these measures in particular. These seven metrics are measures of:

Shared savings opportunities for ACOs participating in the Iowa Wellness Plan begin in their second year of operation and will eventually be contingent upon performance on quality metrics. These quality metrics will be implemented in a phased approach and may include attributed participant experience, primary and secondary prevention, tertiary prevention, population health status, continuity of care, chronic and follow-up care, and efficiency. Implementation of quality metrics is required within three years of the ACO contracting with the Iowa Wellness Plan.

In the first year of operation, one of the bonus payments for which ACOs are eligible will be a medical home bonus payment. The payment will be based on performance on metrics that fall under four categories: (1) person-focused care; (2) first contact with the health care system; (3) comprehensive, coordinated care and (4) transfer of information.

During the CCN Program’s first two years of implementation, any distribution of CCN-S savings will be contingent upon the CCN meeting the established “early warning system” administrative performance measures and compliance under the contract. After the second year of implementation, distribution of savings will be contingent upon the CCN-S meeting department established clinical quality performance measure benchmarks and compliance with the contract.

Maximize alignment of metrics with currently reported metrics in the State and nationally (Medicare ACO, Health Homes, Pathways to Excellence (PTE), Improving Health Outcomes for Children (IHOC), etc.) to the extent feasible and appropriate

Reflect a mix of process and outcomes measurement, and short and long term impacts

Minimize reporting burden to providers, to extent feasible (i.e., keep the number of metrics to a reasonable number )

Measure performance (vs. reporting only) beginning in first performance year

The quality of health services provided by accountable care organizations (ACOs) in Massachusetts will be measured by a Statewide Quality Measure Set being developed in Massachusetts. The Health Policy Commission may also identify additional measures for evaluating ACOs.

The Department of Human Services clarified in its memorandum on flexibility under the Demonstration that participating providers have flexibility in proposing additional quality measures—beyond the core set—that are specific to the population they serve.

Under its State Innovation Model grant to expand the HCDS demonstration, Minnesota has pledged to “provide intensive investments in electronic health record/HIT adoption, secure information exchange, data analytics, practice facilitation, development of risk adjustment methodologies, and quality improvement to remove barriers to integration of care across settings for complex, high-cost patients.”

Section 9 of P.L. 2011, Ch. 114 states that the state’s Department of Human Services “shall evaluate the demonstration project annually to assess whether: cost savings, including, but not limited to, savings in administrative costs and savings due to improved health outcomes, are achieved through implementation of the demonstration project” and “to assess whether there is improvement in the rates of health screening, the outcomes and hospitalization rates for persons with chronic illnesses, and the hospitalization and readmission rates for patients residing in the designated areas served by the ACOs.” The Rutgers Center for State Health Policy will provide outcome evaluation data.New Jersey specified in its 1115 waiver request that evaluation criteria for ACOs would align with the state’s Section 2703 health homes initiative, including measures for rates of health screening, outcomes of hospitalization rates for persons with chronic illnesses and the hospitalization and readmission rates for patients residing within the ACO service area.

In regulations issued in April 2013, the Department of Human Services established that ACO gainsharing plans must select at least five quality measures related to chronic conditions that each participating practice will use and report on, as well as one prevention measure. These include a mix of preventive, at-risk population, appropriate use of providers, and access to care measures. The list of quality metricsproduced by the state also includes mandatory measures.

Performance standards for the quality and utilization of care provided by accountable care organizations (ACOs)

Measures to assess quality and utilization of care provided by ACO

Requirements for the submission of information and data by ACOs and participating providers to facilitate evaluation of ACOs

NYS Public Health Code Article 29-E directs the Commissioner of Health to ensure that New York’s ACO regulations, including reporting and evaluation requirements, are as consistent as possible with regulations released by the Centers for Medicare & Medicaid Services pertaining to ACOs under the Medicare program.

No evaluations have been produced yet. The Oregon Health Authority is required to regularly report to the Oregon Health Policy Board, the Governor, and the Legislative Assembly on its progress in implementing Coordinated Care Organizations, including:

The achievement of benchmarks

Results of evaluations

Rules adopted

Customer satisfaction

Coordinated care organization models of care

Use of patient-centered medical homes

The involvement of local governments in governance and service delivery, and

Health care collaboratives (HCCs) are required to have processes in place to report on measures of quality and cost of health care services, utilization patterns, and availability of services.

The statute requires that HCCs establish standards and procedures relating to the development, implementation, monitoring, and evaluation of:

Evidence-based practices and other processes to improve the quality and control the cost of health care services provided by participating physicians and health care providers, including practices or processes to reduce the occurrence of potentially preventable events

Processes to improve patient engagement and coordination of health services provided by participating physicians and providers

Regulations proposed by the Texas Department of Insurance in September 2012 would require that HCC continuous quality assurance and quality improvement programs include practice evaluation tools including:

Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys developed by the Agency for Healthcare Research and Quality

Agency for Healthcare Research and Quality standards, and

National Quality Forum standards

Further quality measurement and evaluation requirements can be specified in contracts between individual HCCs and payers.

The Department of Health will monitor ACOs using Healthcare Effectiveness Data and Information Set (HEDIS) quality measurement data and has also indicated interest in developing ACO-specific metrics in collaboration with providers and advocates.

In 2013, an Accountable Care Organization (ACO) Measures Work Group in the state worked to select measures for the state’s ACO initiatives. The group relied on a number of criteria, including that measures be: representative of an array of services provided and beneficiaries served by ACO; focused on outcomes to the extent possible; and population-based. After creating a “crosswalk” of over 200 measures from a variety of measure sets, the group came up with two measure sets:

A Core Measure Set of measures for which ACOs have current or pending responsibility for collection,

A Monitoring and Evaluation Measure Set of measures that will be used for programmatic monitoring, evaluation, and planning (collection of these measures will not influence the distribution of shared savings).

Recommended reporting measures for Year 1 of the Medicaid Shared Savings Program include measures drawn from claims data, clinical data, and survey data.